Is Vasopressin Contraindicated in Acute Kidney Injury?
No, vasopressin is not contraindicated in acute kidney injury and is specifically recommended for use in conjunction with fluids in patients with vasomotor shock who have or are at risk for AKI. 1
Primary Recommendation for General AKI
The KDIGO guidelines explicitly recommend using vasopressors, including vasopressin, in conjunction with fluids for patients with vasomotor shock with or at risk for AKI (Grade 1C recommendation). 1 This recommendation does not distinguish between different vasopressor agents, meaning vasopressin is considered an acceptable option alongside norepinephrine and other agents. 1
Context-Specific Considerations
Septic Shock and General Critical Illness
Vasopressin is safe and appropriate in septic shock patients with AKI, as these patients are relatively deficient in endogenous vasopressin, and its administration improves vascular tone and blood pressure. 1
In less severely ill septic patients, vasopressin has been shown to reduce mortality compared to norepinephrine alone, though this benefit was not seen in patients with more severe sepsis. 1
Recent evidence suggests vasopressin may confer renal benefits compared to catecholamine vasopressors, with studies showing lower serum creatinine, higher urine output, and reduced requirements for renal replacement therapy. 2
Specific AKI subphenotypes may respond differently to vasopressin therapy, with one subphenotype (AKI-SP1) showing improved 90-day mortality with vasopressin versus norepinephrine (27% vs 46%, P=0.02). 3
Hepatorenal Syndrome-AKI (HRS-AKI)
Vasopressin analogs (specifically terlipressin) are the treatment of choice for HRS-AKI, not a contraindication. 1
Terlipressin is the vasoactive drug of choice in HRS-AKI treatment, with the best level of evidence coming from placebo-controlled RCTs showing improvement in renal function and decreased need for renal replacement therapy. 1
Vasoconstrictors should be used in HRS-AKI but NOT in other forms of AKI in cirrhosis, as they are only effective when the underlying pathophysiology involves extreme splanchnic vasodilation. 1
Treatment should be initiated early when creatinine is between 2.25-5 mg/dL, as patients with creatinine >5 mg/dL have low response rates. 1
Terlipressin does not require ICU monitoring and can be administered through a peripheral IV line at 1 mg every 6 hours, increased to 2 mg every 6 hours if insufficient response. 1
Mechanistic Rationale
Vasopressin may improve renal microcirculation through unique mechanisms, including differential vasoconstriction of efferent and afferent arterioles within the nephron. 4
Unlike catecholamines, vasopressin does not exacerbate medullary hypoxia and intrarenal inflammation to the same degree. 2
Vasopressin can be particularly useful in catecholamine-resistant vasodilatory shock, where there is insensitivity to norepinephrine. 5
Important Caveats
The choice between vasopressin and norepinephrine should be based on the clinical context, with current guidelines not favoring one over the other in general septic shock. 1
Vasopressin's use is vital in conjunction with fluid resuscitation, not as monotherapy. 1
In cirrhotic patients, vasoconstrictors are only indicated for HRS-AKI specifically, not for other AKI phenotypes like acute tubular necrosis. 1
When using vasopressin analogs like terlipressin in HRS-AKI, concurrent albumin administration should be considered based on volume status, typically 20-40 g/day for 1-2 days. 1